Making the choice between nursing and medicine

Over the last month I have received several comments from readers who have or who are trying to make the choice between nursing and medicine. And may I just say what a great problem we have now, to be able to choose. I’ve been thinking about this and I submit there are three considerations: philosophical, practical, and logistical.

1. Philosophical. Many of you have heard of the “medical model,” the idea that doctors are trained to diagnose and treat disease. Fewer are aware of the various nursing theories, developed by nurses to try to describe the philosophical underpinnings of nursing and attempt to define it’s boundaries.

For example, Dorothea Orem developed the self-care deficit nursing theory, based on the idea that “all patients wish to care for themselves” and it is the job of nurses to restore them to this independence. Roper-Logan-Tierney theory holds a similar view, that disease is defined by disruptions in patient’s ability to perform activities of daily living. There’s a bunch of others along the same lines.

Some of the theory is, frankly, ridiculous verbiage. But it serves the purpose when you are trying to define differences between nurses and doctors. At least as it was in the 1980s, the last time a big general theory was put forward.

Here’s an example of nursing theory versus the medical model. Say you have a 65-year-old man who has been diagnosed with congestive heart failure. The medical model knows that this means the left ventricle of his heart is weak and doesn’t push blood forward into the body so that blood backs up into the lungs causing fluid to accumulate and producing difficulty breathing. If you give drugs to make the heart stronger or decrease the blood volume, the person gets better. The heart is the problem. In nursing theory, the patient has congestive heart failure but the real problem is he can’t breathe, can’t climb stairs like he used to, doesn’t have the stamina he used to have, etc. In other words, his normal functioning in life is disrupted. You have to give the drugs but you also have to address the social, psychological, and educational issues that arise whenever a person can’t do what they’ve always done. The disease is the same, the focus of treatment is different. I will say the medical/nursing lines have blurred: a good nurse knows her medicine and a good doctor treats the whole person. You get the idea.

2. Practical. Of course in practice, all the gobbledygook above goes out the window. Let’s face it. Most doctors and nurses these days do mostly paperwork. Neither gets to take care of people the way they want to. Doctors only get to spend a few minutes with each patient. All the actual care is done by other people. If you really want to take care of people, nurses arguably spend much more time actually laying hands on people and helping them in a physical way. Most doctors do feel they are caring for patients, but it takes a different form. Doctors tend to work longer hours and take more night and weekend call, but nurses are starting to take call also.

The thing about nursing is that nurses have a great deal of responsibility and not a whole lot of power. A nurse’s job is not just to “take orders” but someone does have to do that and nurses do carry out the orders of doctors, and nurses’ work can require a fair amount of physical labor. But as the person who sees the patient the most, nurses also observe and report problems or complications that arise, and are usually the first to notice when something is not right. The nurse might have to seek and “order” for the thing she knows the patient needs, but she/he is the patient’s first line of defense. This advocacy is, in my opinion, the most important thing a nurse does. A good nurse sees what her patient needs and makes sure it happens. Again the lines are blurring, as more nurses have prescriptive authority and do more of the diagnosis.

3. Logistical. Here’s the kicker. The barrier to entry in medicine is extremely high. There are so many hoops to jump through, so many meaningless math classes to ace, so many standardized tests, that some people who would make great doctors get weeded out. It will take you 8 to 12 years to become a practicing physician. The money, time, and hoop-jumping might not be worth it. You don’t need to be exceptionally smart, you just have to be very persistent. Nursing is an easier way to go educationally, but your knowledge base of medicine will be more limited, and you will be working under more supervision. A nurse can go on to get graduate degrees that allow a greater scope of practice, but the educational process is not as complete or as uniform.

Either way you choose, be very sure it is what you really want to do. Both fields are demanding and rewarding and take a great deal of commitment.

Making the choice between nursing and medicine 6 comments

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nurseTTG

One problem in an otherwise good article: “nurses are starting to take call.” I’ve been a nurse for 31 years, and nurses around me have been taking call for my entire career. Until recently, I’d escaped this, but I knew it wouldn’t last forever. Now I practice in hospice, and I, too, get called out in the middle of the night to shepherd families and patients through a crisis, albeit for much, much less compensation than my physician colleagues.

I also take issue with the claim that nurses’ educational process is not as “complete” as physicians. Not sure just what that means exactly, but it certainly sounds like “not as good.” My associate degree, followed by a bachelor’s degree, followed by master’s and doctoral degrees, is pretty darn complete.

Shirie Leng, MD

TTG – thanks for reading. What I mean is that the MD doctorate follows a very prescribed and comprehensive and mandatory route for everyone. Your education is indeed complete and just as good or better, but you charted your own course through it. I guess I should have said “not as uniform” instead of not as complete. Uniform isn’t necessarily good, it just ensures that all the ground is covered for everyone is essentially the same way.

nurseTTG

It sounds as if you had a very bad experience in nursing school. My experience has been quite different. As an ICU nurse, researcher, and educator, I certainly employed logic and the scientific method. I think what distinguishes nursing is that we embrace the knowledge of many disciplines, including medicine. I don’t know of many other professions that do so.

Keith Williamson, MD

My view of nursing is very conflicted. I am a career long proponent, and yet especially in the last 15 years a strident critic. My wife tells her nursing students I am part nurse, and I am not insulted or complemented… maybe bemused is best.

I suggest that above everyone else, nurses don’t know who or what they are. This is in large part because they are left holding the bag so often. They either exceed their education and training or the patient suffers harm.

It makes it hard to contrast the two fields (medicine and nursing) because of vague and evolving definitions. The best definition I have ever seen of nursing was contributed by William Withey Gulll: “Sometimes a trade, sometimes a profession, ought to be a religion.”

Kudos Dr Leng- a very good comparison. One comment- you say quite accurately that the nurse’s most important role is to detect subtle changes in the patient condition- which is in part related to the amount of time spent with the patient vs. the physician. As a floor nurse I did not simply report changes to the physician, I was required to also report what I thought was happening and what I wanted the physician to do. As faculty I teach nurses to assess what is happening physiologically with the patient, report it as such as well as request what they believe will improve or further define the problem.

Lindsay Cookus

I have been a nurse (RN/BSN) for 7 years and decided that I wanted more autonomy and independence with my care for patients. APNS are limited in terms of procedures they can order and preform but I feel that there is a crossing of disciplines in that we can offer not only the holistic and more direct care to the patients but are able to write our own orders and scripts (as I said, with limitations) and both diagnose and treat as we see fit. I think it is important to look at advanced nursing as well when making a decision between the two fields: “medicine” (which I feel should be labeled more appropriately as “physician”) or nursing. I will graduate in May and feel fortunate to have been able to work as an RN while obtaining a higher education with more autonomy. I feel this is also an important factor when deciding between the two fields and, if you don’t have the time or money to go to med school, the RN to APN track is a great alternative. Just my two cents….